We realize that one of the crucial steps in intervening in any infectious disease outbreak, but perhaps most especially this one, is contact tracing, sort of an unholy amalgam of social work, epidemiology and divine intervention. MSF has some people who are incredibly expert at developing systems and networks for such activities under circumstances most of us in the “first” world would find utterly impenetrable.
First of all, as in lots of rural populations in the world, many people here neither read nor write. We tend to spell their names phonetically, but so do they and everyone else. If you learned to read/spell/write phonetically, you may remember how many variations there may be on a theme stringing a few vowels and consonants together, especially when lots of the letters are “k”s, “m”s, “d”s and “g”s, “a”s, “o”s and “u”s.
When you have Abu, Abdul, Abai, Abdulai, etc., just identifying first who you are trying to trace is a huge challenge. Then there is the dilemma of addresses: there really aren’t any - or, at least, not exactly in first world, 911, GPS terms. There may be a house near the market where the Koroma’s live, but it seems half the population of Kailahun is named Koroma . . . you get the picture.
Of course, once the patient is correctly identified, once the name is recorded using an acceptable spelling, and the patient’s home is located, it is only the beginning. Then we have to identify all the people in the home with whom the infected patient may have had contact and whether any of them is or has been sick or has died. If others have in fact been sick, theoretically we should trace their contacts as well. And we must know if they have attended a funeral or burial.
These days, although many do not acknowledge having done so, almost every family in the district has been affected by Ebola directly or indirectly and could reasonably be thought to have attended some sort of burial service or ritual related to death. Then we must know if people have eaten “bush meat”, especially bat or monkey flesh. And we must know whether or not they recently have had a visit to a hospital or clinic where the risk of exposure is especially high, since those are the places where sick people congregate and since, in an epidemic, sick people must be assumed to have the epidemic illness until proven otherwise.
All of this must be accomplished while using precautions that would prevent any further disease transmission if any of the contacts is currently infected and symptomatic. Such precautions range from keeping a safe distance of two or three meters and never touching anything or anybody, to wearing gloves and face mask, to donning full personal protective equipment (PPE) and spraying with chlorine if the home of a known or potentially infected person must be entered.
So imagine how it would be for you, if you were visited - say in a town like Dillon where everybody knows everybody - by a big car with a big logo expelling an uninvited team of strangers in various incarnations of a Martian outfit. Neighbors might really wonder what’s going on, eh?
As a result, even with a lot of preliminary groundwork, we do not always experience unmitigated welcome. Sometimes people are suspicious that we might be bringing Ebola to them. At least we are bringing to them the unwelcome scrutiny of their neighbors. Sometimes local people are angry, feeling that, by bringing patients from outside Kailahun into our treatment center for care, we are increasing their risk and they want us to leave them alone. They are afraid and uncertain.
We are all afraid and uncertain.
In fact, our team’s contact tracing activities are so far pretty limited. MSF has always maintained an emphasis on health education and health promotion activities, on community relations, affiliations and interaction with community leaders, both local and national. These relationships are part of what allow us to do the work we do where we do it, all over the world.
Yet at our core, we are Médecins Sans Frontières: we do medical treatment and intervention. That is our mission, our mandate. We have elaborate, highly developed and sophisticated processes for rapid deployment of field structures, supplies and people to do the work we do.
This is why and how we have been here doing treatment since July, already for three months in this crisis setting. There are literally hundreds if not thousands of other INGO’s (international non-governmental organizations) with greater expertise and structures more focussed to accomplish the critical work of community outreach.
Every day we are asking - where are they? Where are the other international partners to undertake the health education and teach prevention? To help us contain and interrupt the terrible cycle of loved ones infecting those they hold closest? To form the desperately needed network of related and complementary activities that could expand the impact of the work we should all be doing, in the context of a comprehensive approach that would dare to give us hope?
In Haiti, in Aceh, in dozens of other crises over the past 20 years, I am told INGOs have converged so quickly and enthusiastically as to have sometimes created a chaos of good intentions. Certainly I do not hope for the intrusion of more chaos. There is plenty of that already, thank you very much. But on the television, in newspapers, in chat groups and online news media, we hear of the influx of money and effort to address this crisis. Yet here, we are not seeing it.
It may be entirely likely that I have my head down and cannot perceive clearly what is happening. It is true that many of us international workers travel in our insular vehicles from our base where we eat and rest to the treatment center where we work. We try to make sense of what we are seeing and hearing, but we do not move around much in the community, both for reasons of fatigue and for reasons of infection control and prevention.
If it is true that a complex of activities and services is taking shape around us of which I am simply so far unaware, I am thrilled to hear it. Please, in whatever manner is yours, pray that it is so. So far, though, it is not evident to me here in Kailahun, Sierra Leone. My understanding remains that MSF continues to run the only functioning treatment centers in the country. Our center in Bo is now open and is scaling up steadily with the hope of reaching 35 beds by end-week and more than twice that soon thereafter. With the beds here in Kailahun, that should give us almost 150 beds in Sierra Leone.
We need labs, treatment centers and well trained healthcare workers armed with adequate protective gear in every district in the country. We need contact tracers and community organizers, health education and promotion workers, epidemiologists, strategists and collaborators. We need communications and technology specialists. And we need expert managers and supervisors and coordinated distribution throughout the country of all of these activities.
In the end, the truth is that the moment is quickly passing when we could be confident that even a massive, concerted, coordinated effort will be able to prevent not hundreds but thousands, even - according to most recent WHO estimates - hundreds of thousands more deaths. Here in West Africa, the need is desperate, the urgency is now.
Patricia wrote this post on 27th September 2014 in Kailahun, Sierra Leone. For more information about MSF's work on the Ebola outbreak in West Africa please visit msf.org.uk/ebola